Legislature(1995 - 1996)
03/02/1995 02:37 PM House HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HHES - 03/02/95 HB 157 - DIETITIANS AND NUTRITIONISTS JOHN WRAY, incoming president, Alaska Dietetics Association, practicing registered dietitian, spoke in support of HB 157. "Nutrition and dietetics is the integration and application of the principles derived from the sciences of nutrition, biochemistry, physiology, food management, behavioral and social sciences. The primary emphasis is to achieve and maintain the health of the public. All dietitians are nutritionists. Dietitians use the terms interchangeably, like physicians and doctors, or attorneys and lawyers. However, not all nutritionists are dietitians. Nutritionist is a broader, generic term, and therefore in HB 157 provisions are made to ensure that individuals with nutrition practice experience and bachelor's, master's, or doctoral degrees from accredited universities may be recognized as the experts that they are, whether they are dietitians or nutritionists. "Anyone presently can call himself or herself a nutritionist. They sometimes offer expensive and sometimes inappropriate advice and unproven therapies, unless the state government has a law that requires nutritionist licensing. The largest professional organization for nutritionists in the United States, with over 64,000 members, is the American Dietetic Association (ADA). "The 64,000 members meet academic and experience requirements. Eighty percent of ADA members are registered dietitians (RDs), who, after achieving their degree, complete internships and must pass an examination. They must maintain continuing education credits to continue their RD designation. Many Rds have obtained advance degrees beyond their baccalaureate. "The ADA is also recognized as the accrediting agency of the university undergraduate programs in dietetics and nutrition, by the Council of Postsecondary Accreditation and by the U.S. Department of Education. While the ADA has existed since 1917, there are other private accreditation organizations such as the American College of Nutrition, who provide standards with which nutrition professionals can gain membership. Number 684 "However, there are other self-styled nutritionists who provide unproven therapies and counseling to the public. In teleconference testimony, it is hoped that other members will provide anecdotal accounts of clients in Alaska who have been influenced by such individuals. "Nutrition is a relatively young science. Human studies with nutrition is a highly regulated field. Thus nutrition fraud is very widespread. So widespread that a long-term health subcommittee found that health care fraud in the United States cost Americans between $25 billion and $50 billion a year, with nutrition fraud the most common type of health fraud seen. "In Alaska, there are over 120 Rds and nutritionists working in a broad range of settings all over the state, from Ketchikan to Nome. In Alaska, Rds and nutritionists are represented by the Alaska Dietetics Association (AKDA), which is a state affiliate of the ADA. Registered dietitians and nutritionists are a vital component of medical treatment teams at all hospitals in the state. In fact, the joint commission of Accreditation of Health Care Organization and Medicare mandate that nutrition services be provided by Rds in hospitals and nursing facilities. Number 785 MR. WRAY continued his testimony. "In addition, Rds work in a variety of outpatient clinics. They provide nutritional teaching to diabetics; substance abuse clients; patients with heart disease, kidney failure, digestive disorders, eating disorders, high risk pregnancies, strokes, AIDS, and cancer treatment. In addition, Rds and nutritionists can be found in Women, Infants and Children (WIC) clinics and the public health sector at the University of Alaska Anchorage, the school lunch program and sports medicine. "HB 157 will provide the people of Alaska with the following benefits: "One, it will protect Alaskans from potential harm caused by untrained individuals. The citizens of Alaska will know where to find quality nutrition services; Number 808 "Two, it will provide increased protection from the health and economic costs of nutrition fraud; "Three, it will enable the Alaskan consumer to distinguish between qualified and unqualified care providers. The bill does not restrict any one person from offering nutrition information or products, and the people of Alaska should decide who is the expert. With licensure, the state of Alaska is giving the public standards so they can make an educated choice of who they wish to have as their provider; "Four, it will increase the availability of nutrition services to Alaskans by providing for consumers the means to recognize qualified nutrition experts. "HB 157, Dietitians and Nutritionists, will not increase health care costs. When the bill was introduced, included in the HESS Committee members' bill packet was a copy of the document with cost savings of medical and nutrition therapy in Alaska. It shows that dietitians reduce health care costs. They are cost effective. Rds can avert the cost of lifetime care of mentally and physically retarded persons due to low infant birth rate through improved nutritional care during pregnancy. Number 880 MR. WRAY continued. "Proper nutrition reduces the frequency and length of hospital stays for those individuals with chronic diseases. Also, proper nutrition decreases the length of the hospital stay through appropriate nutritional support for those patients with surgery or cancer treatment. It also helps speed the healing of wounds. "It is important to note that HB 157 in no way excludes individuals or professions from practicing nutrition. Page 4 of the bill begins a list of 13 exemptions of groups and/or individuals. Specifically, exemption number 8, on page 5, line 22, makes it quite clear that the AKDA does not wish to stop, restrict or limit efforts of any health food stores, or a provider of natural products. "In a letter received from the National Nutritional Food Association (NNFA) voicing their strong opposition to HB 157, the ADA wonders if the letter would have been sent if the number 8 exemption had been clearly read. Their activities are in no way restricted. If the bill becomes law, it will be business as usual for them. "In the same letter, the NNFA questions why licensure is needed. That question was answered in the testimony already given. They question that the real purpose is money. HB 157 does not create an unfair corner on the nutrition dollar in Alaska. Rds certainly wish to make a living. However, they believe that everyone else who wants to practice nutrition have the right to do so. Rds will not get rich as a result of HB 157. "The letter from the NNFA states that under HB 157 Rds will have a monopoly, which limits freedom of speech. We refer them to the 13 exemptions listed in the bill. Thirty-two other states currently have licensure or certification for Rds and nutritionists. The wording in HB 157 is taken from many of the laws in those 32 states. Number 990 "In the same letter from the NNFA, there are inaccuracies in their attempt to show the action in other states. They list ten states as having defeated licensure in 1992 and 1993. Please note that eight of those states passed licensure in 1994 for dietitians and nutritionists. "The primary opposition in the past for other states with licensure has been that other state affiliates have tried to exclude other people from practicing nutrition. One of the purposes of presenting this bill was to not exclude people from practicing nutrition. It says if they wish to provide nutritional services and label themselves as a dietitian or nutritionist that they are to be licensed by the state, and have the qualifications. MR. WRAY continued his testimony on behalf of the Alaska Dietetics Association. "The ADA is going to present some technical amendments that have come under their attention from discussions with the Division of Occupational Licensing. Most of them are small oversights on the part of the ADA. This language was culled from legislation passed in other states. These amendments are listed number one through five. "There are three changes which the Division of Occupational Licensing wanted addressed. One would allow the division to draft and implement regulations, one would list the authorization of licensing of dietitians and nutritionists to two other appropriate places in the statute Title 8, and the final change would eliminate some excessive wording regarding the qualifications of dietitians for licensure. "Hopefully these can be addressed conceptually, and not hold up the passage of this legislation to its next committee of referral. "In addition, in response to a letter received from the Shackley Corporation, a proposed amendment number 6 in the bill packet changes the wording slightly. The Alaska Dietitians Association also supports this amendment. "The seventh amendment comes from a letter from the American College of Nutrition . This clarifies the language for nutritionists. This is also supported by the AKDA. Number 1109 "In closing, the AKDA wishes to provide the people of Alaska the knowledge for an educated choice when searching for valid, accurate nutrition information from highly skilled motivated professionals. The support of the HESS Committee members is greatly appreciated." DAVID OTTOSON, Alaska Representative for the National Nutritional Food Association, Northwest Division, said that the letter from his organization indicates their opposition to the legislation because it is unnecessary. It does impinge upon freedom of speech with respect to nutritional issues. It gives dietitians and nutritionists a monopoly on information concerning scientific nutrition. MR. OTTOSON said that Mr. Wray responded to the letter from the NNFA by saying there is a need to protect the public from potential harm. Mr. Ottoson was unclear as to where the harm lay. He said that food is what is being discussed. Mr. Ottoson has not heard anybody, other than dietitians, say that there is a serious health problem which exists because of nutritional advice given by someone other than a licensed dietitian. Number 1201 MR. OTTOSON asked if there was any documented examples of harm in the state of Alaska, and what occurred. Mr. Ottoson said that the cost of fraud, discussed by Mr. Wray, is also undocumented. Mr. Ottoson reiterated that Mr. Wray also said that HB 157 will allow the consumer to discern between qualified and unqualified practitioners. MR. OTTOSON thinks the consumer is smart enough to do that without the legislature passing a law to license dietitians. It seems to Mr. Ottoson another example of the government assuming that people are not smart enough to make their own decisions with respect to something that is fairly basic, considering that everyone eats. MR. OTTOSON said the NNFA still remains opposed to the legislation. Mr. Ottoson reminded HESS Committee members about when Mr. Wray discussed the exemptions included in the bill. Mr. Ottoson said the bill regulates nutrition information, yet there are 13 exemptions included in the bill. He finds it ridiculous to have this type of regulation if it requires 13 exemptions in an attempt to think of every situation. Number 1260 MR. OTTOSON said that under this legislation, it is a misdemeanor, punishable by a year in prison or a $1,000 fine to engage in dietetics or nutrition practice. He asked how the bill defines engaging in dietetic or nutrition practice. Dietetics or nutrition practice means the integration or application of scientific principles of food nutrition, biochemistry, physiology, food management, and behavioral and social science to achieve and maintain human health. MR. OTTOSON said therefore, he is exempted when he is talking to people in his health food store about nutrition and nutrition products. So are his employees. But if one of his employees goes home and speaks to a friend about nutrition and recommends a product, under HB 157, this would be technically illegal and punishable. MR. OTTOSON said he just heard about the bill yesterday, and the reason the HESS Committee members had not heard from their constituents about it is because they have not yet heard about the bill. However, Mr. Ottoson assured HESS Committee members that they would be hearing from people about this. Number 1346 CATHERINE REARDON, Director, Division of Occupational Licensing (DOL), introduced herself. CO-CHAIR BUNDE asked her to comment on the fiscal note for HB 157. He asked how many people she thought would apply for the license, and if the fees would cause the program to be self-sustaining. MS. REARDON said the second page of the fiscal note outlines how the DOL reached the cost figures. The DOL is asking for 25 percent of a licensing examiner I for the first two years. A licensing examiner I is the position that provides the staff support for licensing. After two years, the DOL asks that the percentage drop to 10 percent of a licensing examiner I. The reason for that is the first two years is when the bulk of new licensees come into the system. After that, it will just be a matter of re-licensing individuals every two years. MS. REARDON continued that small amounts in the fiscal note were allotted for printing, postage and supplies. These figures were reached based on approximately 120 licensees, as indicated at the bottom of the second page of the fiscal note under "Revenue and Fund Source." It was intended in compliance with the statute that these would cover 100 percent of the costs associated with licensing. MS. REARDON said obviously the DOL estimated what licensing will cost, and, after the first two years, the licensing is reevaluated whether the fees are too high or not high enough to cover costs. The fees are then adjusted for the future. Number 1444 CO-CHAIR BUNDE asked if Ms. Reardon anticipated the initial license will be $280. MS. REARDON said it would cost $280 for two years, if there are 120 licensees. If there are fewer licensees, the cost would need to be higher; if there were more, costs would be lower. CO-CHAIR BUNDE asked if Ms. Reardon anticipated the formation of another board to oversee this process; or if this would simply need a technician, or someone with the appropriate degrees, to supervise. MS. REARDON said this bill does not set up a new board, it allows the division to administer this program directly. The DOL has that power for several other types of professions. In addition to licensing, the DOL would also be handling disciplinary actions and the revocation of licensing. There are additional costs that sometimes come about in terms of the attorney general costs and hearings. All of this would still be possible. Number 1495 CO-CHAIR BUNDE announced at 4:35 p.m. that he and Representative Gary Davis were needed to make a quorum at another meeting. CO-CHAIR TOOHEY announced that a quorum was still present. No action would be taken on this bill today, but the rest of the public testimony would be taken. MS. REARDON said that the division has several suggestions for improvements to the bill, some of which are incorporated into the amendments which have already been offered, and some of which are not. Ms. Reardon said the DOL will be working with the committee and the sponsors. At the next meeting they may have some comments to make at that time. Number 1555 DR. PIZZADILI, Anchorage chiropractor and Alaska state coordinator for Citizens for Health (CEH), testified via teleconference from Anchorage. He explained that CEH is a national, nonprofit consumer health advocacy organization, with members in 11 countries and all 50 states. They are strongly opposed to HB 157, because it unnecessarily and unreasonably creates a monopoly over the practice of nutritional advice-giving. DR. PIZZADILI said an assumption is that without regulation, the public will be exposed to poor nutritional advice. We must remember that some amount of poor advice will occur no matter how well-trained the practitioners are. This is because even the most accomplished professionals are human. As a result, they make mistakes or fail to make themselves completely understood. DR. PIZZADILI said for instance, we might expect that even the best-trained professional will make a serious mistake one-in-every- 1000 patient visits. The issue is not whether poor advice is given, but how often it is given. Without some comparative statistical evidence to substantiate a claim for poor advice- giving, the purpose for which this bill exists is null and void. DR. PIZZADILI said in some matters of serious concern to the public, experts, and those choosing to maintain exclusive rights to advising the public on nutrition-related matters, have been remarkably incorrect in giving the public advice. DR. PIZZADILI continued that for nearly 50 years, dietitians and home economists have advised the public to substitute margarine for butter, despite a 1942 study in rats that demonstrated that margarine increased cholesterol levels and contributed to processes which in turn contributed to arterial sclerosis. Suddenly, many reports in medical literature cautiously advises the public that maybe they have been in error for 50 years. Number 1653 DR. PIZZADILI added that it was only 15 years ago that dietitians called anyone a charlatan or a quack if they purported synthetic food additives might adversely affect behavior. This bill restricts the practice of exchanging information on nutrition to a very small group. Thirty-four states have legislation, but only 14 have mandatory licensing. Two of these states require no formal training. Number 1694 JULIANNE MINARIK, dietitian, Providence Hospital, testified from Anchorage. She said that everyone can be a nutritionist, because everyone eats. Not everyone, however, can be a dietitian because they go to school for a long period of time to learn about nutrition, nutrition aspects within states of disease, etc., etc. Ms. Minarik sees less insurance of critical issues protecting some of the most vulnerable citizens, especially children and pregnant women. MS. MINARIK said she is a dietitian assigned to the prenatal unit, pediatric unit, pediatric intensive care unit, and the neonatal intensive care unit in Providence Hospital. Providence Hospital acts as a referral center for the state of Alaska. Inappropriate nutrition advice to pregnant women can and has led to premature delivery of infants. In many cases, these infants are critically ill. MS. MINARIK said that poor nutritional advice can lead a pregnant woman to deliver a newborn who is below the gestational age. Prematurity means many months, perhaps a very long time in the newborn intensive care unit. These costs are both financial and emotional. Nutrition counseling and intervention by a professional can make the difference between a healthy baby and one which will be born too soon and may never fully recover. Also, the dietitian functions as a part of the health care team in the treatment of premature infants and babies. MS. MINARIK explained that feeding for a newborn infant can start out with one to two drops and can go up after that. Needless to say, the smallest error in the formulation for these tiny patients can be disastrous. FRANCES JAYNES, registered dietitian, Providence Hospital, also testified from Anchorage. She said that asking for licensure of dietitians in the state of Alaska is a means to assure that nutrition counseling and medical nutritional therapy is provided by qualified individuals only. Dietitians have a minimum of a bachelor's degree from an accredited university. Many have master's degrees or doctorates. In addition, dietitians receive postgraduate training from an accredited program. MS. JAYNES said once this basic training is completed, competency is further checked through a national registration examination. A person who passes this examination must then maintain continuing education to stay registered. This process assures the consumer of the competency of the dietitian. MS. JAYNES continued that according to the Surgeon General's report on nutrition and health, eight out of ten leading causes of death, including heart disease, stroke, some types of cancer and diabetes are related to diet and alcohol. Appropriate intervention from qualified, well-trained health care professionals such as dietitians can make a very positive impact. Number 1848 MS. JAYNES said her main clinical functions at Providence Hospital involve nutrition support of critically ill and injured adults, and nutrition education of cardiac patients. Nutrition support involves appropriate promotion of nutrition products taken in a specific manner over a period of weeks. Additionally, these patients usually have specific metabolic needs, which must be met in order to facilitate recovery. Incorrect or inappropriate nutrition support can cost not only time and money, but also the patient's life. MS. JAYNES said the cardiac patients are educated to change their lifestyle, including diet, in order to recover and prevent the need for further intervention such as coronary artery bypass surgery. Without proper care, even newly grafted coronary arteries may not last more than eight years. Since there are many patients in their 50s, 40s and even 30s, appropriate counseling is essential for long-term survival. MS. JAYNES urged the HESS Committee members to support licensing dietitians as a means of consumer protection from a multi-billion dollar diet industry. Number 1915 BEVERLY WOOLEY, Legislative Network Coordinator, Alaska Dietetic Association, testified via teleconference from Anchorage in support of HB 157. MS. WOOLEY a nutritionist currently working for the municipality of Anchorage, Department of Health and Human Services. One of the missions of the state and local health agencies is to protect and promote health, and prevent disease and injury. One of the core public health functions that have been put forth and is essential to this mission is the assurance to clients that they can get the necessary high-quality effective health services available to the public. MS. WOOLEY said there is a quality assurance issue at stake here. An effective means of insuring quality is through licensing of health professionals including dietitians. Most other health care providers are licensed. Even hair stylists are licensed in Alaska. Presently, anyone in Alaska can call him or herself a dietitian or nutritionist and offer sometimes expensive, sometimes dangerous advice to clients. MS. WOOLEY continued that passage of HB 157 and thereby licensing dietitians and nutritionists would enable the public to identify individuals who are qualified by education, experience and examination to provide quality nutrition care services and would also provide increased protection to the public from the health and economic costs of nutrition fraud. MS. WOOLEY said that she previously taught at Anchorage Community College and one day, after a giving a lecture on nutrition during pregnancy, a young student approached her in tears. This normal- weight, pregnant student informed Ms. Wooley that she and her husband had been told by a "nutritionist" that she was overweight and needed to lose weight immediately to insure the health of her unborn baby. This information was not only inaccurate but dangerous. It was given to her by an untrained individual who had presented him or herself as a nutritionist. CO-CHAIR TOOHEY asked if Ms. Wooley had written this testimony and sent it to the HESS Committee members. Ms. Wooley said that parts of it had been sent to committee members, but she was also currently providing new testimony. Number 2024 MS. WOOLEY reminded the HESS Committee members that many consumers currently have mistakenly sought advice from unqualified persons because they were not aware that the profession was not licensed. Testimony was heard earlier that people should have the intelligence to judge for themselves. People do not realize it is not a licensed profession. They have called Ms. Wooley when they are caught off-guard and asked, why are they allowed to do this, doesn't the government protect the public. Most people, at this point, do not know that dietitians are not licensed. MS. WOOLEY said it is the position of the American Dietetics Association as well as the Alaska Dietetics Association that licensure of dietitians and nutritionists is important for protecting the health and the welfare of the citizens of Alaska. Number 2060 DEBRA MESTAS, WIC nutritionist and certified breast feeding consultant, Anchorage WIC program; and renal dietitian at the Alaska Kidney Center, testified via teleconference from Anchorage that she is in charge of thousands of critically ill patients who rely, daily, on what they eat. MS. MESTAS explained that kidney patients can live or die within hours according to what they eat or drink. Much of this is not known by other people who have no physiological knowledge of kidney function or medication use. These people are at risk of becoming hospitalized and permanently damaged. They can also die from inaccurate dietary advice. You will not hear this from untrained people because they do not know how the kidney works. MS. MESTAS said this is also the case with people who have no training in cardiac functions or diabetes. She would encourage the HESS Committee members to pass HB 157 because of all the problems she has seen with patients coming to her with advanced renal failure from inappropriate nutritional advice and supplements that were "prescribed" by untrained individuals who had no business treating these patients because they had no knowledge of their physiological problems. MS. MESTAS added these untrained professionals are usually not in contact with any medical professionals. They do not know the medications the client is on. They do not know the interactions of their pills or gimmicks that are occurring in the patient's body. The public is being put at severe risk when they have these severe diseases. MS. MESTAS also sees infants who are malnourished from inappropriate nutritional advice, and their parents have been encouraged to not give formula or breast milk within the first year. These patients sometimes die or fail to thrive. She thanked HESS Committee members for considering the importance of HB 157. CO-CHAIR TOOHEY closed HB 157 to public testimony. HB 157 would stay in the HESS Committee for an undetermined amount of time.
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